IM cirrhosis

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Author:
TerryZ
ID:
249330
Filename:
IM cirrhosis
Updated:
2013-11-29 13:26:48
Tags:
internal medicine IM gastrointestinal GI gastric intestinal cirrhosis
Folders:
IM
Description:
Internal medicine - cirrhosis
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  1. Cirrhosis - facts
    • D: C liver dz- fibrosis, disrupt liver arch, //nodules; irreversible
    • I: blood flow->portal HTN
    •     xBiochem fns (Alb & clot fact synth)
    •     -> ascites,periph edema,splenomeg
    • C: EtOH liver dz (10-15%)
    •     C Hep B/C
    •     Drugs- APAP tox, methotrexate
    •     AI, prime/2nd biliary cirrhosis
    •     Inher metab dz- hemochrom,Wilson
    •     Cong 2/2 R HF, constrict pericard
    •     α-antitrypsin def; NASH
    •     hep veno-occl dz (post BMT)
  2. Cirrhosis - S/Sx
    • Early: Asympt
    • PHTN: ascites,varices,hemor,edema,SM
    • Sex: gynecomastia, testic atrophy
    • Derm: palm eryth, spid ang, caput med
  3. Cirrhosis - Dx
    Liver bx
  4. Child-Turcotte-Pugh score
    • Meas cirrhosis sev, predict morb/mort
    • _             1         2         3  _
    • Enceph  None MildCtl Advnc
    • Ascites  None MildCtl PoorCtl
    • T. Bili   <2.0    2-3     >3.0
    • Album  >3.5  2.8-3.5  <2.8
    • PT/INR<1.7  1.7-2.3  >2.3
    •                   Survival%
    • Class  points  1yr    2yr
    •    A     5- 6    100   85
    •    B     7- 9      81   57
    •    C   10-15      45   35
  5. Cirrhosis - portal HTN - S/Sx
    • splenomegaly
    • ascites
    • varices->bleed
    • hepatic encephalopathy
    • caput medusa
  6. Cirrhosis - portal HTN - Dx
    • S/SXs
    • Paracentesis
    • Thromocytopenia, leukopenia
    • Doppler US, CT/MRI
  7. Cirrhosis - portal HTN - Tx
    • Specific complication: treat
    • Vasoconstr: splanch&portal ven flow vasopressin,somatostatin,non-select BB
    • Vasodil: alter inter-hep resist             NTG, long-acting NO3s, prazoin
    • TIPS: transjug intrahep port-sys shunt
  8. Cirrhosis - varices - S/Sx
    • Caput medusae: disten abd wall veins
    • Rectal: hemorrhoids
    • GI: Esoph 90%, Gastr 10%
    •      //bleed,/enceph,fatigue,pallor,tachy
  9. Cirrhosis - varices - Dx
    • Hepatic venous pressure gradient
    • /INR
    • TCP
  10. Cirrhosis - varices - Tx
    • PPx: ~sel BB (propanolol,nad-,tim-)
    • Init: Hemodyn stabl (IVF)
    • IV abx: PPx ~SBP
    • IV octreotide: 3-5d
    • UGI endo: emergent
    • Varices: ligat'n, band, sclero, octre,   balloon tamp,TIPS,shunts,liv Xplant
  11. Cirrhosis - ascites - etiology
    • E: PHTN & HoAlb
    • DDx: cirrh, CHF, C renal dz, //fluid, TB, malig, HoAlb, liver aldo inactiv
  12. Cirrhosis - ascites - S/Sx
    • Abd dist,fluid wave,shift dull (>1.5L)
    • /wt,early satiety,SOB,hernias evident
  13. Cirrhosis - ascites - Dx
    • Abd US: >30mL, conf PHTN/splenomeg
    • paracent: SBC,RBC,cx,alb,Gr,LD,TG,cyt
    •               infectn >=250 pmn/mm3
    •               PHTN - SAAG>1.1 g/dL
  14. Cirrhosis - ascites - Tx
    • Bed rest, Na, dour (furos+spiron)
    • Paracentesis, therapeutic
    • TIPS (effective 90%, improve 3 mo)
    • Liver Xplant (w/o 75% mort if refract)
  15. Cirrhosis - hep enceph - facts
    Toxic metabolites reach brain (50%)
  16. Cirrhosis - hep enceph - precip
    • Alkalosis
    • HoK (2/2 diur)
    • Sedating drugs (narc,tranq,sed,sleep)
    • GI bleed
    • Syst infection
    • Surg
    • HoVol, HoNa, Hypoxia
    • N-load (GI bleed, /prot, azot, constip)
    • A liver progression, superimposed
    • Portal-systemic shunts
  17. Cirrhosis - hep enceph - S/Sx
    • ment fn,confus,poor conc,stupor/coma
    • Asterixis (flapping tremor)
    • Rigidity, HReflexia
    • Fetor hepatics (must odor of breath)
  18. Cirrhosis - hep enceph - Dx
    • /NH3
    • HGammaglob
    • TCP, LeukoP, PCP
    • /CSF glutamine
    • CT/MRI - cortical atrophy(basal ganglia)
  19. Cirrhosis - hep enceph - Tx
    • Exclude other causes, ID precip factors
    • Lactulose (prevent NH3 absorb)
    • Bowel cleanse (enema, gastric lavage)
    • Neomycin (kills bowel flora->NH3)
    • Protein restrict (1g/kg/day), veggies
    • Rifaxamin
  20. Cirrhosis - hepatorenal synd.
    • Indicates: ESLD
    • Cause: progressive RF 2/2 HoPerfus'n
    • Precip: Infect, diur, LV paracentesis
    • Sx: azot(/BUN:Cr), oliguria, HoNa, HoTN, urine Na(<10), GFR
    • Tx: liver Xplant
    • Prev: paracentesis+alb
    •          SBP- Alb+cefotaxime
    •          EtOH hep- pentoxifylline
  21. Cirrhosis - SBP - acronym
    Spontaneous Bacterial Peritonitis
  22. Cirrhosis - SBP - facts
    • Infected ascetic fluid (in 20% hosp'd)
    • ESLD, high mort (20-30%), ?ascites
    • High recur (70% 1st yr)
  23. Cirrhosis - SBP - agents
    • E. coli MC
    • Klebsiella
    • S. pneumo
    • single org
  24. Cirrhosis - SBP - S/Sx
    • F, Abd P, AMS
    • N/V, rigors, D, hep enceph, malaise
    • HoTN, tachycardia
    • Rebound tenderness
  25. Cirrhosis - SBP - Dx
    • Azotemia: /Urea, Cr
    • Paracen: WBC>500,PMN>250,GS?Cx(-)
  26. Cirrhosis - SBP - Tx
    • Start b4 Cx results if PMN>250cells/mL
    • 1st: broad spect abx - 3G ceph or FQs
    •       cefotaxime, ceftazidime
    • Improve: 24hrs; repeat paracent 2-3d
    • PPx: prior SBP, GI bleed, TProt<1g/dL
    •        norfloxacin, levo- (risk UTI/resist)
  27. Cirrhosis - hyperestrinism
    • D: excessive secr estrone,estadiol,estriol
    • Sx: spider ang, palm eryth, gynecom, testicuar atrophy
  28. Cirrhosis - coagulopathy
    • 2/2: synthesis of clotting factors
    • /PT: (prothrombin time), /PTT if severe
    • Vit K: ineffective (dz liver can't use it)
    • Tx: FFP
  29. Cirrhosis - hepatocellular carcinoma
    HCC - present in 10-15%
  30. Cirrhosis - Tx
    • Underly dz: xEtOH, interferon Hep B/C
    • Avoid: APAP, EtOH (cause liver inj)
    • Compl: varic bleed,ascites,hep enceph
    • Xplant: only hope for cure (xEtOH 6mo)

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